Motion after motion was carried at the BMA special representative meeting (SRM) last Tuesday, with doctors aligned in calling for price competition to be scrapped, and clear that the any willing provider policy would damage the NHS.

But a crucial motion on whether the BMA policy of 'critical engagement' had failed and whether it should now oppose the Bill 'in its entirety' teased out the first sign of a crack in that allied front.

The motion split the profession, but was narrowly lost as 54% voted against all-out opposition to the Bill.

BMA chairman Dr Hamish Meldrum says BMA members were right to vote this way, warning it would be unwise to 'put all your negotiating eggs in one basket'.

Dr Meldrum: voting against all-out opposition to the reforms is right

But he says the vote does not mean the BMA supports the Bill. 'We are against large parts and we will continue to oppose those damaging bits,' he says.

'Vote for common sense'Londonwide LMCs chief executive Dr Michelle Drage also believes the outcome is a 'vote for common sense'. 'We can still fight the nasty bits of the Bill,' she says. 'This meeting is recognition that it is not over and there is a long way to go.'

But for the 44% who voted for all-out opposition to the Bill the outcome of this motion may signal a lost opportunity and leave them wondering what the SRM achieved.

Speaking before the vote, Keep Our NHS Public cochairwoman Professor Wendy Savage said the BMA should tell the government it no longer wanted to discuss the Bill, because it was 'unamendable'.

Dr George Rae, secretary of Newcastle and North Tyneside LMC, says the meeting galvanised 'very significant' opposition to the reforms.

Dr Rae: 'Doctors have real concerns that the values and the ethos of the NHS are disappearing'

'Look at the way the representatives reacted on enforced competition and price competition,' he says. 'They have concerns that the values and ethos of the NHS are disappearing.'

GPC negotiator Dr Chaand Nagpaul says: 'There has been huge consensus about the issues we oppose. We need the government to listen to doctors because it needs doctors to make the NHS work.'

Dr Nagpaul: 'We need the government to listen to the voice of doctors because it needs doctors to make the NHS work'

Whether the government now acts on the BMA's concerns could define whether the vote to reject outright opposition to the Bill was the right move.

Many representatives are concerned that the government has not been prepared to listen to the profession thus far.

But others see events at the Liberal Democrat spring conference this month, where delegates branded the NHS reforms 'damaging' and backed a series of amendments, as evidence that the tide could soon change.

Dr Meldrum says because the Liberal Democrats are part of the coalition, there is 'stuff we can work on there'.

GPC member Dr Helena McKeown agrees. Following the SRM she asked BMA president Sir Michael Marmot to look at how the reforms could widen health inequalities.

She says this is the 'antithesis' of what Liberal Democrats who believe in fairness and progressive policies want, and may help BMA lobbyists win over the party's MPs.

Dr McKeown says this approach is more likely to pay dividends than angry protests. 'This is what we do best, not banner-waving or marching,' she says.

Dr Evan Harris, a public health doctor and former Liberal Democrat MP, says there is now a 'critical mass' of support for changes to the Bill.

The Bill and GP commissioning will go ahead, he says, but pressure within the coalition and from groups such as the BMA mean it is now likely the market reforms proposed will be watered down.

Doctors angry about the reforms will hope he is right.

Although Dr Meldrum says all-out opposition to the Bill would be 'high risk', trying to negotiate with a government that has been criticised for not listening to doctors could yet prove equally dangerous.